The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

Disturbed Sleep Pattern related to difficulty staying asleep

Disturbed Thought Processes related to chronic insomnia

Risk for injury related to somnambulism

Risk for Impaired Gas Exchange related to sleep apnea

Answer and Explanation

The Correct Answer is C

The priority nursing diagnosis for this client should be Risk for injury related to somnambulism. Somnambulism, also known as sleepwalking, can put the client at risk for injury as they may engage in activities while not fully conscious. The client's report of falling asleep while driving and almost being involved in an accident further highlights the potential risk for injury. It is important for the nurse to address this risk and develop a plan to ensure the client's safety.

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Correct Answer is D

Explanation

When collecting equipment to administer a unit of packed red blood cells, the nurse should use 250 mL of normal saline to initiate the IV for this transfusion ³. Normal saline is the only compatible solution to use with blood or blood components ³. The other options (100 mL of 5% dextrose and 1/2 normal saline, 1,000 mL of lactated Ringer's solution, and 500 mL of 5% dextrose and water) are not appropriate IV ﬂuids to use when administering a unit of packed red blood cells.

A. Not talkative B. Pale and diaphoretic C. "Leave me alone" D. Restlessness E. Encourage or provide oral hygiene after mealtime.

Correct Answer is C

Explanation

Subjective data refers to information that is reported by the client and cannot be directly observed or measured by the healthcare provider. In this case, the statement "leave me alone" is an example of subjective data that the nurse should document. This information provides insight into the client's feelings and emotions and can help guide the nurse's care and interventions.

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The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV ﬂuid should be used to initiate the IV for this transfusion?

Correct Answer is D

Explanation

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed and says "leave me alone." Which subjective data should the nurse document?

Correct Answer is C

Explanation

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

During a particularly heated staﬀ meeting regarding staﬀ assignments, the nurse manager makes this comment: "When you all can come to a decision, let me know and we'll move on from there." This leader is best identified as which of the following?

A client has been prescribed a clear liquid diet. What food or ﬂuids will be served?

A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." One of the following statements demonstrates that the nurse appropriately evaluated this goal.

A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem?

A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

The nurse is using the PED model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply.

The nurse is admitting a new client to the unit. The nurse notes that this client would need an alternate meal choice when the menu specified pork for a meal. Members of which cultural group might request an alternative meal choice?